Authored By:
U.S. Department of Housing and Urban Development

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Purpose of Form: The Violence Against Women and Justice Department Reauthorization Act of 2005 (“VAWA”) protects qualified tenants, participants, and applicants, and family members of tenants, participants, and applicants, who are victims of domestic violence, dating violence, or stalking from being denied housing assistance, evicted, or terminated from housing assistance based on acts of such violence against them.

Use of Form: This is an optional form. A PHA (Public Housing Authoirity), owner or management agent presented with a claim for continued or initial tenancy or assistance based on status as a victim of domestic violence, dating violence or stalking (herein referred to as “Victim”) has the option to request that the victim document or provide written evidence to demonstrate that the violence occurred. The Victim has the option of either submitting this form or submitting third-party documentation.

Please download the form to learn more about options for victims of domestic violence in this situaiton.

Also, click the links below for a guide to VAWA Housing protections available to victims of domestic violence.

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